PT in ICU & ICU Acquired Weakness

Physical Therapy in the Intensive Care Unit

Guiding Questions

  • What problems are encountered by patients in the ICU?

  • What is ICU acquired weakness? Explain the consequences.

  • What is the role of PT in the ICU?

  • Discuss the physical therapy exam priorities and considerations for a patient in the ICU.

  • What is the Physical Function Test in the ICU (PFIT)?

  • What is the Function in Sitting Test (FIST)?

  • What is the John Hopkins Highest Level of Mobility Score (JH-HLM)?

  • What is the Activity Measure for Post-Acute Care (AMPAC)?

  • What criteria are used to determine when a patient is ready for mobilization in the ICU?

  • What are the different interventions that can be utilized for patients in the ICU?

  • What are the criteria for termination of PT?

  • What problems may be encountered with PT in the ICU with respect to lines/drains/tubes?

  • What precautions must be taken?

Learning Objectives

  • Discuss problems encountered by patients in intensive care.

  • Describe the role of physical therapy in the ICU and its significance to patient recovery.

  • Identify components of physical therapy examination in the ICU setting, emphasizing clinical assessments.

  • Describe physical therapy interventions in the ICU and their goals.

Primary Problems Encountered in the ICU

Presence of Immobility

Immobility can lead to a cascade of problems, significantly impeding recovery. Artificial airways can further exacerbate these issues, introducing complications related to respiratory function and overall health.

Problems from the Presence of Artificial Airways

  • Loss of Humidification: Artificial airways bypass the upper respiratory tract, leading to a loss of humidification which can dry the mucous membranes, potentially causing irritation and increasing risk for infections.

  • Impaired Airway Clearance: Patients with tracheostomy or endotracheal tubes face challenges in clearing secretions, increasing the likelihood of respiratory complications.

  • Ineffective Cough: The presence of artificial airways diminishes the effectiveness of voluntary or spontaneous coughs, leading to secretions retention.

  • Atelectasis: This occurs due to ventilation/perfusion (V/Q) mismatch often associated with retained secretions, resulting in collapsed lung areas.

  • Ventilatory Muscle Weakness: Prolonged immobility and reliance on mechanical ventilation contribute to weakness in muscles essential for respiration.

Problems from Immobility

  • Pooling of Secretions: When patients lie still, secretions can accumulate, increasing infection risk.

  • Atelectasis: Inactivity may result in collapsed lung tissue due to obstruction of airflow.

  • Pressure Injuries: Sustained body positioning heightens risk of pressure injuries, which can lead to severe complications if not addressed.

  • Adaptive Shortening of Muscles: Lack of movement negatively affects muscle elasticity, leading to reduced range of motion and increased contractures.

  • Reduced Nutrition and Exercise Tolerance: Prolonged bed rest results in diminished nutritional status and exercise tolerance, contributing to a cycle of weakness.

  • Depression and Cognitive Changes: Long-term immobilization can lead to depression and cognitive decline, which can complicate recovery.

ICU Acquired Weakness

ICU acquired weakness is a profound weakness that escalates beyond what is expected simply from extended bed rest. It often manifests in patients who have been on mechanical ventilation for 4 to 7 days and is frequently seen in cases such as sepsis or acute respiratory distress syndrome (ARDS).

Role of Physical Therapy in the ICU

Importance of Physical Therapy

  • Maintaining Airway Clearance: Physical therapy interventions play a crucial role in preventing the accumulation of secretions in compromised respiratory systems.

  • Preventing Atelectasis and V/Q Mismatch: Regular movement and targeted breathing exercises are vital for maintaining lung function, preventing atelectasis, and promoting effective gas exchange.

  • Preventing Pressure Injuries: Physical therapists implement strategies for frequent repositioning to avoid pressure injuries.

  • Improving Mobility: Facilitating mobility enhances patient independence and overall recovery.

  • Decreasing ICU Acquired Weakness: Proactive physical therapy interventions can counteract the muscle weakening associated with extended bed rest and immobility.

  • Improving Exercise Tolerance: Gradual reconditioning helps rebuild physical capacity that may have diminished during hospitalization.

  • Preventing Cognitive Changes: Regular physical therapy engagement aids in maintaining cognitive function through patient interactions and activities.

Physical Therapy Examination

Key Data Considerations

It is essential to assess circulation, ventilation, and respiration to determine therapy candidacy in ICU patients. Identifying contraindications is also crucial for safe intervention.

Important Aspects of Examination

  • Circulation, Ventilation, and Respiration: Continuous monitoring of vital signs, including heart rate, respiratory rate, blood pressure, peripheral pulses, and oxygen saturation, is critical for therapy effectiveness.

  • Sensory Integrity and Skin Integrity: Routine evaluation of sensation and skin assessment for pressure injuries is necessary for comprehensive care.

  • Functional Performance: Utilizing standardized tools such as PFIT, JH-HLM, and AMPAC contributes to objective measurement of patient progress.

Key Assessment Tools

  • Physical Function in the ICU Test (PFIT): Combines four essential components—sit to stand, marching on the spot, shoulder flexion, and muscle strength assessment. Performance is evaluated based on repetitions and overall endurance.

  • Function in Sitting Test (FIST): This clinical assessment evaluates sitting balance across 14 tasks encompassing daily activities, typically completed in under 10 minutes. Scoring is conducted by a therapist, providing a quick evaluation of balance.

  • Johns Hopkins Highest Level of Mobility Score (JH-HLM): Tracks patient mobility levels daily to monitor highest achieved mobility and timestamps various activities, ensuring a comprehensive mobility history.

  • Activity Measure for Post-Acute Care (AMPAC): This tool employs a “6-Clicks” method for assessing mobility across fundamental tasks, effectively predicting patient discharge destinations and rehabilitation needs.

Minimum Criteria for PT in ICU

To initiate physical therapy in the ICU, patients must demonstrate:

  • Mental Alertness: Ability to follow commands and required interactions.

  • Hemodynamic Stability: Stable vital signs indicative of overall health.

  • Acceptable Respiratory Status: Sufficient lung function and oxygenation to manage activity demands.

  • Risk Mitigation: Consideration of therapy should include risk assessment for safe exercise or activity.

Termination Criteria for PT

Critical Values

Physical therapy may need to be halted if:

  • MAP < 60 mm Hg: This indicates potential compromised perfusion and warrants immediate attention.

  • Sedation Levels: Increased sedation affecting responsiveness and patient engagement may necessitate therapy cessation.

  • Increased Respiratory Support Needs: Sudden changes in ventilation or respiratory support requirements may indicate instability, providing grounds to discontinue therapy.

Interventions

Goals for PT

The overarching goals of physical therapy in the ICU include:

  • Preventing Secondary Complications: Actively addressing complications arising from immobility.

  • Promoting Functional Mobility: Encouraging and facilitating patient movement, which is critical for psychological and physical recovery.

Types of Interventions

  • Positioning: Appropriate positioning is crucial to maintaining airway patency and allowing for adequate function.

  • Breathing Training: Targeted exercises are designed to strengthen respiratory muscles and improve tidal volume.

  • Therapy Progression: Begin interventions with passive movements, progressively advancing to assisted and active range of motion exercises as the patient stabilizes.

Monitoring During Interventions

Therapists must continually monitor patients for signs of cardiorespiratory distress, discontinuing therapy at the first sign of adverse symptoms.

Problems Associated with PT in ICU

Precautions with Lines/Tubes

Physical therapists must maintain vigilance concerning the presence of lines and tubes to ensure patient safety:

  • Tracheostomy Tubes: Ensuring these do not obstruct airways during patient repositioning is vital.

  • IV Lines: Optimal positioning should prevent disruption or complications stemming from IV access.

  • Feeding Tubes and Catheters: Attention to feeding tubes, urinary catheters, and other lines prior to therapy sessions is critical for ensuring patient safety.